METHODS

Design:

Allocation:

Blinding:

Follow up period:

1 year after index hospital admission.

Setting:

6 academic and community hospitals in Philadelphia, Pennsylvania, USA.

Patients:

239 English speaking patients ⩾65 years of age (mean age 76 y, 57% women) who were admitted to hospital from home with HF,
alert and oriented, reachable by telephone, and residing ⩽60 miles from the admitting hospital. Exclusion criterion was end
stage renal disease.

Patient follow up:

MAIN RESULTS

At 1 year after the index admission, the APN TC group had a lower rate of hospital readmission or death than the usual care
group (table); estimated median event free survival was higher in the APN TC group than the usual care group (241 v 131 d, p = 0.026). The APN TC group also had fewer overall readmissions (104 v 162, p<0.047) and fewer comorbidity related readmissions (23 v 50, p<0.013). The groups did not differ for quality of life or functional status at 1 year. Mean total costs (adjusted for
unequal follow up) were lower in the APN TC group than the usual care group ($7636 v $12 481, estimated mean cost savings per patient $4845, 95% CI $1301 to $8976).

CONCLUSIONS

In elderly patients admitted to hospital with heart failure, a 3 month, comprehensive, transitional care intervention directed
by advanced practice nurses increased time to readmission or death, reduced readmissions, and reduced healthcare costs. Quality
of life and functioning did not differ from usual care.

Commentary

The trial by Naylor et al provides evidence of the benefit of comprehensive discharge planning and post-discharge support for older patients with HF,
a highly prevalent condition with substantial associated morbidity and mortality. The study is of good quality, and although
follow up falls slightly below the generally accepted criterion of 80%, use of intention to treat analysis and equal attrition
from the study groups increases our confidence in the findings.

A recent systematic review had comparable results for a range of similar interventions in this patient group,1 although Naylor et al found improved outcomes for comorbid conditions specifically. Other studies have been unable to demonstrate such an effect,
although similar trends have been found.2,3

Extended post-discharge support for patients with HF should be implemented as a routine. Services should be established as
a multidisciplinary endeavour, with consideration of the detail of implementation, in light of evidence that post-discharge
support given in the form of increased clinic visits or telephone follow up may not be as effective.1 Although cost savings, as shown by Naylor et al, are possible, fragmented healthcare systems may impede the development of these services by not reimbursing providers. Such
disincentives will exist in any system where the focus for outcomes and resource allocation is on individual services rather
than the effect of all services.